Sedation Regimens Research Articles

Comparison of ketamine-propofol mixture (ketofol) and midazolam-meperidine in endoscopic retrograde cholangiopancretography (ERCP) for oldest old patients.

Background and aim: Endoscopic retrograde cholangiopancreatography (ERCP) requires moderate-to-deep conscious sedation. Combinations of ketamine and propofol (ketofol) and of midazolam and meperidine were analyzed using the bispectral index (BIS). There is no research on the use of ketofol on very elderly patients. The aim of this study is to use BIS and offer insight into the use and safety of ketofol sedation for oldest old patients undergoing ERCP.Materials and methods: For the ERCP procedure, 168 patients aged 85+ years were enrolled in a 2-year retrospective single center study. Seventy-five patients received midazolam-meperidine (MM) sedation in 2016, while 75 patients received ketofol (KP) sedation in 2018.The two groups were compared for patient data, procedure duration, Ramsay Sedation Score (RSS), heart rate (HR), blood pressure (BP), and pulse oximetry (SpO2), BIS, facial pain score (FPS), time to achieve BIS, recovery time, and complications. The total amount of rescue medication was recorded.Results: The two groups did not differ by patient data or procedure duration (p>0.05). Group KP had significantly higher systolic and diastolic BP, HR, and SpO2 values and lower BIS scores than Group MM (p=0.0001). The two groups did not differ by time to achieve BIS scores (p>0.05). Group KP had significantly fewer complications and a shorter recovery time than Group MM (p<0.001).Conclusion: Ketofol induced sedation results in more stable vital signs and fewer complications than the midazolam-meperidine sedation regimen during ERCP in oldest old patients, indicating that ketofol can be an alternative to midazolam-meperidine.

Gabapentin for Peri-operative Pain Management for Office Uterine Aspiration: A Randomized Controlled Trial [10H

INTRODUCTION: Gabapentin, used to treat neuropathic and chronic pain, has also been used to reduce post-surgical pain in a variety of clinical settings. We investigated if the addition of gabapentin to the routine oral sedation regimen would reduce peri-operative pain from uterine aspiration. METHODS: IRB approval and informed consent were obtained. We enrolled patients seeking first trimester uterine aspiration with oral sedation in a randomized double-blind placebo-controlled trial to receive placebo or 600 mg of oral gabapentin in addition to oral sedation and paracervical block. Our primary outcome was pain 5-minutes after procedure measured on a VAS (100 mm) pain scale. Secondary outcomes measured included pain at a variety of time points, post-operative pain medication use, anxiety and nausea. This study was powered to detect a 16 mm difference in pain. To assess the effect of gabapentin at the 5-minute post-op assessment, we fit a linear regression controlling for baseline pain. RESULTS: 96 patients were randomized (95 completed study protocol). Patients receiving gabapentin reported similar pain scores compared to placebo at the 5-minute post-op assessment (p = 0.56). Anxiety measures were similar between groups at several time points. Gabapentin was well-tolerated and side effects were similar between groups. 15% of women receiving gabapentin versus 31% receiving placebo recorded using narcotic pain medication within 24 hours of the procedure (p = 0.06). CONCLUSION: Gabapentin did not have a significant effect on the 5-minute post-operative pain measurement or anxiety. The trend toward decreased opioid usage in the post-operative period amongst the gabapentin users warrants future investigation.

Sedation and Anesthesia in Gastrointestinal Endoscopy: Indian Scenario

AbstractSedation in endoscopy is a drug-induced depression in the level of consciousness. Traditionally, the sedation regime most commonly used for conscious sedation during gastrointestinal (GI) endoscopy was a combination of opioids and benzodiazepines. However, in the last two decades, propofol is regarded as the sine qua non agent for gastroenterological endoscopic sedation. A thorough risk evaluation before the procedure and monitoring during the procedure are paramount. In elective endoscopy, unplanned adverse events are rare, occurring in 1.4% of procedures. All currently available guidelines state that the endoscopist is not permitted to administer propofol and to monitor the patient. This task must be done by an additional person, who has the sole responsibility of administering the sedative and monitoring the patient. Various scoring systems exist for defining the discharge criteria, of which the Aldrete score is the most commonly used.

Propofol-based sedation does not negatively influence oxygenator running time compared to midazolam in patients with extracorporeal membrane oxygenation.

Patients on extracorporeal membrane oxygenation are frequently in need for sedation. Use of propofol has been associated with impaired oxygenator function due to adsorption to the membrane as well as lipid load. The aim of our retrospective analysis was to compare two different sedation regimens containing either propofol or midazolam with respect to oxygenator running time. Midazolam was used in 73 patients whereas propofol was used in 49 patients, respectively. In the propofol group, veno-arterial-extracorporeal membrane oxygenation was used predominantly (84%), while veno-venous-extracorporeal membrane oxygenation was used more often in the midazolam group (64%). Oxygenator running time until first exchange was 7 days in both groups ( p = 0.759). No statistically significant differences could be observed between the subgroup of patients receiving lipid-free (n = 24) and lipid-containing (n = 31) parenteral nutrition, respectively. Laboratory parameters like triglycerides, free hemoglobin, fibrinogen, platelets, and activated partial thromboplastin time were not significantly different between both sedation regimens ( p = 0.462, p = 0.489, p = 0.960, p = 0.134, and p = 0.843) and were not associated with oxygenator running time. The use of propofol as sedative seems suitable in patients undergoing extracorporeal membrane oxygenation therapy.

Dexmedetomidine/propofol versus dexmedetomidine/ketamine versus dexmedetomidine as a sole agent for pediatric sedation during MRI

BackgroundPropofol use in MRI procedures is growing worldwide especially for infants and children. Propofol causes unintended deep sedation and respiratory depression. The safety and efficacy of dexmedetomidine–propofol versus ketamine–dexmedetomidine versus dexmedetomidine alone as a based sedation regimen in specific age range of children is the study concern.ObjectiveThe aim of this study is to compare the efficacy of dexmedetomidine/propofol mixture, dexmedetomidine/ketamine, and dexmedetomidine alone for pediatric MRI sedation.Patients and methodsNinty infants and children whose body weight is more than 10 kg were enrolled in a double-blind comparative study and assigned into three equal groups for sedation, group (DK) dexmedetomidine/ ketamine, group (DP) dexmedetomidine/propofol, and group (D) dexmedetomididne alone. All patients were given premedication in the form of oral midazolam 0.5 mg/kg 30 min before the procedure. Sedation was according to group: Group (DK) received ketamine 1.5 mg /kg intravenous bolus as a loading dose and maintenance dose done by dexmedetomidine infusion with a concentration of 0.004 mg/ml and infusion rate of 1 μg/kg/h for the first 10 min then reduced infusion dose to be in between 0.6 and 1 μg/kg/h to keep the patient sedated to a Ramsay sedation score more than 4. Group (DP) received propofol 1.5 mg/kg intravenous bolus as a loading dose, then maintenance dose infusion was a mixture of dexmedetomidine with a concentration of 0.004 mg/ml and propofol 4 mg/ml; this combination is compatible (Trissel et al., 2002; Cayo, 2013). This combination will be started by a loading dose of 1 μg/kg/h for the first 10 min then 0.6 to 1 μg/kg/h, sedated with a Ramsay sedation score of more than 4. Group (D) received dexmedetomidine with a dose of 2–3 μg/kg/h as loading for 10 min then 0.6 to 1 μg/kg/h to keep the patient sedated with a Ramsay sedation score of more than 4.ResultsThere was a significant difference between the DP group induction recovery time, hemodynamics, and Ramsey sedation score up to 5 min after the induction to the other two groups, and there was a significant difference between the DK group to the other two groups concerning emergence phenomena (agitation, altered perception, hallucination) and sedation failure.ConclusionThe combination of dexmedetomidine to propofol with a low dose for sedation during MRI gives better induction + recovery time, improves hemodynamics, and decreases incidence of emergence phenomena and sedation failure.

The KEEP SIMPLEST Study: Improving In-House Delays and Periinterventional Management in Stroke Thrombectomy-A Matched Pair Analysis.

Although the treatment window for mechanical thrombectomy (MT) in patients with acute ischemic stroke (AIS) has been extended in recent years, it has been proven that recanalizing treatment must be administered as soon as possible. We present a new standard operating procedure (SOP) to reduce in-house delay, standardize periinterventional management and improve patient safety during MT. KEep Evaluating Protocol Simplification In Managing Periinterventional Light Sedation for Endovascular Stroke Treatment (KEEP SIMPLEST) was a prospective, single-center observational study aimed to compare aspects of periinterventional management in AIS patients treated according to our new SOP using a combination of esketamine and propofol with patients having been randomized into conscious sedation (CS) in the Sedation versus Intubation for Endovascular Stroke TreAtment (SIESTA) trial. Primary outcome was early neurological improvement at 24h using the National Institutes of Health Stroke Scale, and secondary outcomes were door-to-recanalization, recanalization grade, conversion rate and modified Rankin Scale (mRS) at 3months. Door-to-recanalization time (128.6 ± 69.47min vs. 156.8 ± 75.91min; p = 0.02), mean duration of MT (92.01 ± 52min vs. 131.9 ± 64.03min; p < 0.001), door-to-first angiographic image (51.61 ± 31.7min vs. 64.23 ± 21.53min; p = 0.003) and computed tomography-to-first angiographic image time (31.61 ± 20.6min vs. 44.61 ± 19.3min; p < 0.001) were significantly shorter in the group treated under the new SOP. There were no differences in early neurological improvement, mRS at 3months or other secondary outcomes between the groups. Conversion rates of CS to general anesthesia were similar in both groups. An SOP using a novel sedation regimen and optimization of equipment and procedures directed at a leaner, more integrative and compact periinterventional management can reduce in-house treatment delays significantly in stroke patients receiving thrombectomy in light sedation and demonstrated the safety and feasibility of our improved approach.

Evaluations of Morphine and Fentanyl for Mechanically Ventilated Patients With Respiratory Disorders in Intensive Care: A Systematic Review of Methodological Trends and Reporting Quality

BackgroundMechanically ventilated patients with respiratory disorders may require sedatives, such as opioids. ObjectivesTo define methodological trends, gaps, and the reporting quality of the comparative clinical and economic evaluations of fentanyl and morphine in ventilated patients in the intensive care unit. MethodsWe conducted a literature review of the MEDLINE, Embase, OVID, ScienceDirect, Springer Link, and EconLit databases, comparing studies in the management of ventilated patients with respiratory disorders in the intensive care unit using either fentanyl or morphine, or both. We assessed the methodological aspects of the literature characteristics and trends of, for example, modeling, data sources, cost calculation, and data analysis, appraising the quality of reporting via the CONsolidated Standards Of Reporting Trials, STrengthening the Reporting of OBservational studies in Epidemiology, and the Consolidated Health Economic Evaluation Reporting Standards checklists. ResultsAmong 1327 articles, 33 (comprising 22 in adults, 8 in neonates, and 3 in pediatrics) met the inclusion criteria. No head-to-head morphine versus fentanyl evaluations explicitly confined to subjects with respiratory conditions were undertaken. Studies relied on various scales to measure the sedation level as a primary study outcome, limiting the comparability of study conclusions. Seven articles of adults were identified to be economic studies from the hospital perspective. On the basis of different endpoints, the same sedation regimen performed differently in various studies. None of the randomized controlled trials, observational cohorts, or pharmacoeconomics studies met most of the assessed reporting quality criteria. ConclusionsOur review identified poor reporting quality and high heterogeneity of methods used, potentially limiting the degree to which studies could be interpreted, decisions could be influenced, and findings could be generalized.

A Novel Research Method for Determining Sedative Exposure in Critically Ill Patients.

Although potent sedative and opioid drugs are some of the most commonly used medications to manage pain, anxiety, and discomfort in critically ill patients, conducting clinical trials where sedative and opioid medications are outcome variables within a longitudinal research design can be a methodological challenge. The purpose of this article is to provide in detail a conceptual discussion of the concept and analysis of sedative exposure: A novel research analysis method for aggregating sedative and opioid medication doses from disparate drug classes commonly administered to critically ill patients and used by our team in several clinical research studies. Comparing the dose of each sedative and opioid administered to an individual patient (within a defined time interval) to all other patients in a research study receiving the same medications allows for ranking of dosages for each medication by quartiles. Rank values for all sedatives and opioids received can be summed to a single value resulting in a Sedation Intensity Score. In addition, a simple count of how many hours at least one dose of a sedative or opioid medication has been administered can determine sedation frequency. This method can allow for comparison of sedative exposure with medications from disparate drug classes and for analysis of estimates of change in medication use over time. This novel research analysis method can overcome the challenges and limitations of determining changes in sedative and opioid medication regimens in cohort and clinical trial study designs.

The effects of obesity on sedation-related outcomes of advanced endoscopic procedures.

OBJECTIVE:Current literature covers limited data on the safety of sedation in advanced endoscopic procedures in obese patients. The present study aims to evaluate the association between obesity and the frequency of sedation-related complications in patients who were undergoing advanced endoscopic procedures.METHODS:A retrospective chart analysis of 1172 consecutive patients, meeting the inclusion and exclusion criteria for this study and undergoing intravenous ketamine-propofol (ketofol) sedation for endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) procedures were evaluated. The patients were classified into three groups according to their body mass index (BMI) (kg/m2). Group I comprised patients with a BMI between 25 and 30, group II with a BMI between 30 and 35, and group III with a BMI between 35-40. The sedation-related outcomes in the form of adverse events, and airway interventions were compared between the groups.RESULTS:For analysis, out of the 1172 available records, 289 patients had a BMI between 35-40 and were predominantly male patients. The total adverse events were more common in obese patients, with apnea (in 5.5% patients in group I, 5.7% in group II, 22.8% in group III p<0.000), oxygen desaturation (in 7.7% patients in group I, 9.4% in group II, and 27.7% in group III p<0.000), and airway obstruction (in 4.9% patients in group I, 5.4% in group II, 22.8% in group III, p<0.000). Moreover, the obese patients more frequently required airway interventions, including airway placement, suctioning and bag-mask ventilation.CONCLUSION:Higher BMI was associated with an increased frequency of sedation-related complications. However, we concluded that ketofol sedation regimen could be used safely in obese patients during advanced endoscopic procedures by skilled anesthesia providers.

Prospective Experience of High-flow Nasal Oxygen During Bronchoscopy in 182 Patients: A Feasibility Study.

High-flow nasal oxygen (HFNO) has recently gained popularity during administration of anesthesia in a variety of circumstances, including apneic oxygenation. Fully qualified anesthesiologists provide sedation for our outpatient bronchoscopy service. We adopted this therapy to assess its efficacy providing optimal conditions (using a variety of sedation regimens) for patient and bronchoscopist. We aimed to conduct a prospective feasibility evaluation. We collected data from all patients undergoing outpatient bronchoscopy or endobronchial ultrasound with anesthesiologist administered sedation over 21 months. Demographic data, high-flow settings, sedation techniques, and oxygen saturations (SpO2) were collected for each patient. Feedback from the bronchoscopists and anesthesiologists was recorded. Failure of the technique was defined as abandonment of the procedure or prolonged desaturation not amenable to basic airway maneuvers or increase in oxygen flow rate. All 182 patients underwent satisfactory bronchoscopy or endobronchial ultrasound. Mean age was 63 (±14) years. High-flow rate varied from 10 to 70 L/min. All patients received a remifentanil infusion and 175 (96%) had a propofol infusion. SpO2 before the procedure were lower (96%) than the highest saturation during the procedure with high flow (100%, P<0.0001). Ten patients transiently desaturated to <89%. Some had their flow rates increased, others required a transient jaw thrust, but all patient's saturations rapidly returned to satisfactory levels. One patient became apneic during sedation. Respiration returned after pausing the sedation and oxygen SpO2 remained above 93% throughout. All bronchoscopists and anesthesiologists were happy with the use of HFNO. HFNO has been shown to be effective in the outpatient bronchoscopy setting. Further evaluation regarding flow rates and levels of sedation is required.

A comparative study of midazolam alone or in combination with dexmedetomidine or clonidine for awake fiberoptic intubation

Background:Awake fiberoptic intubation (AFOI) is the gold standard technique for managing patients with anticipated difficult airway. Conscious sedation is desirable, not only to make the procedure more tolerable and comfortable for the patient but also to ensure optimal intubating conditions. Ideal sedation regime for AFOI should provide comfort, cooperation, hemodynamic stability, and amnesia along with maintenance of spontaneous respiration. Several sedative agents have been assessed over the past two decades for this purpose but α2 agonists appear to be the favorable choice owing to its sedative, analgesic, amnestic, and sympatholytic properties along with good hemodynamic profile.Aims:The present study has been aimed to recognize the characteristics of dexmedetomidine, clonidine, and midazolam and to compare their efficacy in providing optimal intubating conditions as well as hemodynamic stability during AFOI.Settings and Design:A prospective double-blind randomized study done in tertiary care hospital.Materials and Methods:Sixty patients of American Society of Anesthesiologists physical status Classes I and II aged 18–60 years with anticipated difficult airway were randomly allocated into three groups. All the patients received injection midazolam bolus followed by sedation infusion of midazolam, dexmedetomidine, and clonidine according to the allocated group. Primary outcome includes the time to achieve Ramsay Sedation Score (RSS) ≥2, time taken in intubation, intubation score, comfort score for fiberoptic insertion and intubation, and patient tolerance after intubation. The secondary outcome was hemodynamic, and respiratory variables include changes in heart rate (HR), mean arterial pressure (MAP), oxygen saturation (SpO2), and respiratory rate during the procedure.Statistical Analysis:All data were recorded, summarized, tabulated, and statistically analyzed using SPSS 16.0 version (Chicago, Inc., USA). The data were presented in mean ± standard deviation. P < 0.05 was considered as statistically significant.Results:All the three groups were comparable in terms of demographic profile. Time to achieve RSS ≥2 and mean intubation time was significantly less in Groups D and C as compared to Group M (P < 0.001). Among groups, Group D took least time to achieve RSS ≥2 (5.53 ± 0.74) and mean intubation time (4.53 ± 0.91). Similarly, overall intubation score, comfort, and patient tolerance score were significantly more in Group M as compared to Groups D and C (P < 0.001). Among the groups, Group D achieved least intubation score (3.80 ± 0.67) and comfort score (2.53 ± 0.74). Although Groups D and C have a lower mean HR and MAP during the procedure and intubation compared to Group M, the incidence of SpO2 is most frequent with clonidine.Conclusions:Patients who received α2 agonist were calmer and cooperative with less pain and discomfort than the patients who received midazolam. Dexmedetomidine allows better endurance, stable hemodynamics, and patent airway as compared to clonidine.

Interventions for preventing intensive care unit delirium in adults.

Interventions for preventing intensive care unit delirium in adults.

Safety and Utility of Continuous Ketamine Infusion for Sedation in Mechanically Ventilated Pediatric Patients.

The selection of sedative medications for mechanically ventilated pediatric patients remains an ongoing clinical challenge. Although continuous ketamine infusion has been used in this population, support for its use remains largely anecdotal. This study describes a single institution's use of ketamine infusions as part of a sedation protocol in the pediatric intensive care unit (PICU). This was a retrospective study of children who received ketamine infusions as part of a multidrug sedation protocol in a 12-bed PICU at a tertiary children's hospital. Outcomes included effectiveness of ketamine infusion in providing adequate sedation as determined by State Behavioral Scale (SBS) scores and incidence of adverse events. A total of 22 children receiving ketamine continuous infusion as part of a multidrug sedation protocol from February 2014 through October 2015 were eligible and enrolled in the study. Ketamine continuous infusion was administered in addition to at least 2 other sedation infusions at an average rate of 1.02 ± 0.50 mg/kg/hr, with a range of 0.07 to 2.0 mg/kg/hr. The duration of ketamine was 65.7 ± 41.01 hours, with a range of 19 to 153 hours. There was no significant change in SBS scores before and after initiation of ketamine infusion. Although not statistically significant, patients with inadequate sedation prior to starting ketamine required fewer bolus sedation doses and had improved sedation after ketamine was started. There were no reported adverse events. The addition of a ketamine infusion as part of a multidrug sedation regimen was at least as effective as patients' regimen prior to ketamine addition in this population of intubated pediatric patients, with no adverse events.

Comparison of two schemes of daily arousal and comfort analgesia and sedation in patients on mechanical ventilation in intensive care unit

To explore the efficacy of comfort analgesia and sedation in patients with mechanical ventilation in intensive care unit (ICU). Eighty patients with mechanical ventilation admitted to ICU of Pingxiang People's Hospital from June 2017 to May 2018 were enrolled, and they were randomly divided into control group and observation group by random number table method, with 40 patients in each group. The control group was given a daily analgesic and sedation regimen with critical-care pain observation tool (CPOT) 0-3 and Richmond agitation-sedation scale (RASS) maintained at -3 to -4. The observation group was given comfort analgesic sedative scheme with immediate analgesia and sedation score, CPOT 0-1 and RASS -1-0. Under these circumstances, patients could be waken up at any time, feel comfortable and cooperate with treatment. The duration of mechanical ventilation, the length of ICU stay, ventilator associated pneumonia (VAP) rate, delirium rate and sedatives drugs usage were compared between the two groups. There were no significant differences in baseline data such as gender [male (cases): 25 vs. 28], age (years old: 55.2±8.3 vs. 56.1±7.9), acute physiology and chronic health evaluation II (APACHE II: 19.4±3.0 vs. 19.8±3.2) and etiology [sepsis (cases): 13 vs. 16, chronic obstructive pulmonary disease (cases): 12 vs. 10, acute lung injury (cases): 8 vs. 9, hemorrhagic shock (cases): 5 vs. 4, cardiogenic shock (cases): 2 vs. 1] between the observation group and the control group (all P > 0.05). Compared with control group, the duration of mechanical ventilation and the length of ICU stay were significantly decreased in observation group (days: 5.6±1.9 vs. 7.8±2.7, 6.6±2.1 vs. 9.8±2.5, both P < 0.01), the VAP rate and delirium rate were significantly decreased (17.5% vs. 40.0%, 25.0% vs. 47.5%, both P < 0.05), the average dose and total dose of sedative drugs were significantly reduced [propofol average dose (mg): 200.3±94.2 vs. 455.7±143.1, propofol total dose (mg): 1 266.4±419.7 vs. 2 682.6±734.1; dexmedetomidine average dose (g): 726.6±241.1 vs. 1 312.7±841.6, dexmedetomidine total dose (g): 5 647.3±2 215.2 vs. 9 864.5±4 268.0; all P < 0.01]. The therapy of comfort analgesia and sedatives on ICU patients with mechanical ventilation, can decrease the treatment time, lower the risk of adverse events, and reduce the dosage of sedatives drugs.

Variation in Sedation and Neuromuscular Blockade Regimens on Outcome After Cardiac Arrest.

Sedation and neuromuscular blockade protocols in patients undergoing targeted temperature management after cardiac arrest address patient discomfort and manage shivering. These protocols vary widely between centers and may affect outcomes. Consecutive patients admitted to 20 centers after resuscitation from cardiac arrest were prospectively entered into the International Cardiac Arrest Registry between 2006 and 2016. Additional data about each center's sedation and shivering management practice were obtained via survey. Sedation and shivering practices were categorized as escalating doses of sedation and minimal or no neuromuscular blockade (sedation and shivering practice 1), sedation with continuous or scheduled neuromuscular blockade (sedation and shivering practice 2), or sedation with as-needed neuromuscular blockade (sedation and shivering practice 3). Good outcome was defined as Cerebral Performance Category score of 1 or 2. A logistic regression hierarchical model was created with two levels (patient-level data with standard confounders at level 1 and hospitals at level 2) and sedation and shivering practices as a fixed effect at the hospital level. The primary outcome was dichotomized Cerebral Performance Category at 6 months. Cardiac arrest receiving centers in Europe and the United states from 2006 to 2016 PATIENTS:: Four-thousand two-hundred sixty-seven cardiac arrest patients 18 years old or older enrolled in the International Cardiac Arrest Registry. None. The mean age was 62 ± 15 years, 36% were female, 77% out-of-hospital arrests, and mean ischemic time was 24 (± 18) minutes. Adjusted odds ratio (for age, return of spontaneous circulation, location of arrest, witnessed, initial rhythm, bystander cardiopulmonary resuscitation, defibrillation, medical history, country, and size of hospital) was 1.13 (0.74-1.73; p = 0.56) and 1.45 (1.00-2.13; p = 0.046) for sedation and shivering practice 2 and sedation and shivering practice 3, respectively, referenced to sedation and shivering practice 1. Cardiac arrest patients treated at centers using as-needed neuromuscular blockade had increased odds of good outcomes compared with centers using escalating sedation doses and avoidance of neuromuscular blockade, after adjusting for potential confounders. These findings should be further investigated in prospective studies.

Abstract P-480: α2 AGONISTS IN PAEDIATRIC CRITICAL CARE SEDATION: A MULTI-SITE RETROSPECTIVE COHORT STUDY

Aims & Objectives: This study aimed to evaluate if an opioid based sedative regimen with an α2 agonist adjunct (clonidine or dexmedetomidine) produces a non-inferior proportion of time at target sedation compared to a control group with an α2 agonist, while conferring additional benefits such as reduced opioid and benzodiazepine co-administration. Methods A retrospective cohort study at two Irish PICUs of first admission mechanically ventilated children receiving an opioid infusion between January 2014 and June 2016 was conducted. Children were categorised into an α2 agonist group or a control group. Using recorded COMFORT Behaviour Scale (CS) scores a proportion of time at target sedation (CS 11–16) for each included patient while mechanically ventilated was calculated alongside extraction of opioid and benzodiazepine use and clinical characteristics. A propensity score model was constructed to evaluate treatment effects including all identified relevant confounders. The pre-defined non-inferiority threshold for the primary outcome was set at 12.5%. Results One thousand and sixty-six admissions were included (685 clonidine,43 dexmedetomidine and 338 control). The α2 agonist based regimen produced a non-inferior time at optimal sedation +4.2% (95% CI -2.4 to 10.9%) though total morphine use was not statistically decreased at -1.74 µg/kg/hr (95% CI -4.83 to 1.34 µg/kg/hr) versus control. Benzodiazepine use was also not decreased. Conclusions A sedation regimen with an α2 agonist adjunct produces a non-inferior time at target sedation to a control group. However, no associated opioid or benzodiazepine sparing effects were observed in initial analysis to justify their inclusion in the sedative regimen

Tu1063 SEDATION IN DIGESTIVE ENDOSCOPY - PROPOFOL VERSUS TRADITIONAL SEDATIVE AGENTS: SYSTEMATIC REVIEW WITH META-ANALYSIS

Sedation schemes for gastrointestinal endoscopic procedures using propofol have been increasingly employed. This drug is superior to traditional sedation regimens (benzodiazepines and opioids) in relation to the onset of action and post-procedure recovery profile of patients. However, there may be some disadvantages: need for administration by trained physicians, narrow therapeutic window, absence of antidote, increased risk of cardiorespiratory events. To perform a systematic review and meta-analysis for comparison between sedation schemes containing propofol alone and / or associated with traditional sedatives in endoscopic procedures of the TGI Search in MEDLINE databases, EMBASE, Cochrane Central Register of Controlled Trials, LILACS, randomized clinical trials comparing propofol versus traditional sedatives associated or not with propofol, published until October 2017, addressing the following outcomes: adverse effects, patient satisfaction with sedation received, endoscopist satisfaction with sedation administered, dose of propofol used, recovery time after the procedure. Meta analysis performed using Revman5 software version 5.39. From the 6532 articles, resulting from the initial search, 23 clinical trials were included, comprising 3854 patients. There was a high heterogeneity among the studies included during the meta-analysis of all outcomes, despite the performance of sensitivity and bias analysis. There were no statistically significant differences between the sedation schemes compared to the outcomes analyzed. There was no difference between using propofol alone or in combination with traditional sedative agents in endoscopic gastrointestinal tract procedures.

Association of Blood Pressure With Short- and Long-Term Functional Outcome After Stroke Thrombectomy: Post Hoc Analysis of the SIESTA Trial.

Outcome after mechanical thrombectomy for ischemic stroke may be influenced by blood pressure (BP). This study aims to assess the association of BP changes during general anesthesia versus conscious sedation with functional outcome after mechanical thrombectomy. SIESTA (Sedation vs Intubation for Endovascular Stroke Treatment) was a monocentric randomized trial of general anesthesia versus conscious sedation during mechanical thrombectomy involving BP target protocols. In this post hoc analysis, BP measurements were divided into 4 phases: preintervention, prerecanalization, postrecanalization, and postintervention. We examined the association between BP and functional outcomes (defined by improvement of 24-hour National Institutes of Health Stroke Scale [NIHSS] and 3-month modified Rankin Scale). We found no association between the difference in systolic BP, diastolic BP, and mean arterial pressure from baseline to the different phases of intervention and NIHSS change after 24 hours. Only baseline diastolic BP was associated with a reduced improvement in NIHSS (β=0.17, P<0.01). There was no association of BP drops with a change in modified Rankin Scale at 3 months. About sedation, only baseline mean arterial pressure preintervention revealed significant associations (β=0.16, P<0.01) with less change in 24-hour NIHSS in conscious sedation group. Otherwise, there was no association for differences of any of the BP measurements with a change in 24-hour NIHSS and long-term functional outcome either in general anesthesia or the conscious sedation group when analyzed separately, consistent with our findings in the entire cohort. Doses of propofol (β=0.84, P=0.04) and norepinephrine (β=1.87, P=0.01) administered during intervention before recanalization were associated with reduced improvement of NIHSS at 24 hours. In a setting, where both sedation regimes general anesthesia and conscious sedation were performed according to strict protocols directed at avoiding BP extremes, our findings suggest that peri-interventional BP drops were not associated with either early neurological improvement or long-term functional outcome. URL: https://www.clinicaltrials.gov. Unique identifier: NCT02126085.

Sedation in Pediatric Esophagogastroduodenoscopy.

Pediatric esophagogastroduodenoscopy (EGD) has become an established diagnostic and therapeutic modality in pediatric gastroenterology. Effective sedation strategies have been adopted to improve patient tolerance during pediatric EGD. For children, safety is a fundamental consideration during this procedure as they are at a higher risk of severe adverse events from procedural sedation compared to adults. Therefore, a detailed risk evaluation is required prior to the procedure, and practitioners should be aware of the benefits and risks associated with sedation regimens during pediatric EGD. In addition, pediatric advanced life support by endoscopists or immediate intervention by anesthesiologists should be available in the event that severe adverse events occur during pediatric EGD.

Comparison of two sedation regimens during targeted temperature management after cardiac arrest

PurposeAlthough guidelines on post-resuscitation care recommend the use of short-acting agents for sedation during targeted temperature management (TTM) after cardiac arrest (CA), the potential advantages of this strategy have not been clinically demonstrated. MethodsWe compared two sedation regimens (propofol-remifentanil, period P2, vs midazolam-fentanyl, period P1) among comatose TTM-treated CA survivors. Management protocol, apart from sedation and neuromuscular blockers use, did not change between the two periods. Baseline severity was assessed with Cardiac-Arrest-Hospital-Prognosis (CAHP) score. Time to awakening was measured starting from discontinuation of sedation at the end of rewarming. Awakening was defined as delayed when it occurred after more than 48 h. Results460 patients (134 in P2, 326 in P1) were included. CAHP score did not significantly differ between P2 and P1 (P = 0.93). Sixty percent of patients awoke in both periods (81/134 vs. 194/326, P = 0.85). Median time to awakening was 2.5 (IQR 1–9) hours in P2 vs. 17 (IQR 7–60) hours in P1. Awakening was delayed in 6% of patients in P2 vs. 29% in P1 (p < 0.001). After adjustment, P2 was associated with significantly lower odds of delayed awakening (OR 0.08, 95% CI 0.03–0.2; P < 0.001). Patients in P2 had significantly more ventilator-free days (25 vs. 24 days; P = 0.007), and lower catecholamine-free days within day 28. Survival and favorable neurologic outcome at discharge did not differ across periods. ConclusionsDuring TTM following resuscitation from CA, sedation with propofol-remifentanil was associated with significantly earlier awakening and more ventilator-free days as compared with midazolam-fentanyl.